NCC232465_FRO Submitted_20230914

Check if this project is ARPA-funded 71
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality, Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1
Project Name Brookwood Subdivision -Phase 4
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding Through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Moore City or Township Carthage
3
Highway/Street— Star Ridge Road
Latitudeideounal degreesL35.2900 Longitude(decimal degrees)-79,4113
Approximate date land -disturbing activity will commence: November
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.88 Ac
g. Amount of fee enclosed: $ 900 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example. 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed LNk No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity;
Name Wes Caddwell
E-mail [e-mail]
Phone: Office # 910-585-0475 Mobile #
g. Landowner(s) of Record (attach accompanied page to list additional owners):
Tri South Builders, Inc
Name
P.O Box 805
Current Mailing Address
Carthage NC
City State
910-585-0475
Phone: Office # Mobile #
3100 Vass Carthage Road
Current Street Address
28327 Carthage
Zip City
NC
State
28327
Zip
10 Deed Book No. 5887 Page No, 121 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Tri South Builders, Inc
Company Name
P.O Box 805
[e-mail]
E-mail Address
3100 Vass Carthage Road
Current Mailing Address Current Street Address
Carthage NC 28376 Carthage NC
City State
Phone: Office # 910-585-0475
Zip City State
Mobile #
'r43WAFl
Zip
Note: If the Financially Responsible Parry is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City Y �J State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed_
Landowner 4 of Record-
Name Phone- Office # Mobile #
Current Mailing Address Current Street Address
City
Deed Book No.
Landowner 5 of Record:
Name
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Current Mailing Address
City State
Deed Book No.
Phone: Office # Mobile #
Current Street Address
Zip city
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
James W. Caddell
Type or print name
Signature
President
Title or Authority
• 3'_' --
Date
I, —,-(Zn('C3E�, i-,llQ--)\ , a Notary Public of the County of
State of North Carolina, hereby certify that )cCrie5 VJ Gx3de k k appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this l�:) day of LA , 20--)3
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